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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 53  |  Issue : 5  |  Page : 184-190

Factors affecting mortality in trauma patients with more than three rib fractures


1 Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
2 Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan

Date of Submission06-Mar-2020
Date of Decision03-May-2020
Date of Acceptance24-Jul-2020
Date of Web Publication19-Oct-2020

Correspondence Address:
Ching-Hua Hsieh
No. 123, Ta-Pei Road, Niao-Song District, Kaohsiung City 833
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_24_20

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  Abstract 


Background: In patients with rib fractures, a higher number of rib fractures has been reported to increase the risk of mortality. This study aimed to explore the risk factors for mortality in patients with more than three rib fractures.
Materials and Methods: This retrospective study involved a data review of 35,154 trauma patients registered in the Trauma Registry System of a single urban trauma center in Taiwan from January 1, 2009, to December 31, 2018. In total, 1,296 patients who had more than three rib fractures were identified and categorized into two groups: mortality (n = 42) and survival (n = 1,254). Univariate and multivariate logistic regression analyses were applied to identify the independent effects of predictive variables of mortality in patients with multiple rib fractures.
Results: Patients who died had a significantly higher number of rib fractures (6.9 ± 3.0 vs. 5.5 ± 1.7, P < 0.001), lower Glasgow Coma Scale (GCS) score (median [interquartile range, Q1–Q3]; 12.5 [3–15] vs. 15.0 [15–15], P < 0.001), and higher injury severity score (ISS) (median [Q1–Q3]; 35.0 [26–41] vs. 16.0 [13–22], P < 0.001) than those who survived. The mortality group had a 10.4-, 3.8-, and 2.9-fold higher odds of sustaining a sternal fracture, pulmonary contusion, and hemopneumothorax, respectively. Multivariate logistic regression analysis revealed that age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.05–1.12; P < 0.001), number of rib fractures (OR, 1.2; 95% CI, 1.04–1.47; P = 0.016), GCS (OR, 0.8; 95% CI, 0.76–0.93; P = 0.001), ISS (OR, 1.2; 95% CI, 1.10–1.21; P < 0.001), blood transfusion (OR, 4.3; 95% CI, 1.37–13.40; P = 0.013), and hemopneumothorax (OR, 15.5; 95% CI, 2.769–86.62; P = 0.002) were the significant independent risk factors for mortality.
Conclusion: This study revealed that age, number of rib fractures, GCS, ISS, blood transfusion, and hemopneumothorax were the significant independent risk factors for mortality of the patients with more than three rib fractures.

Keywords: Mortality, rib fractures, trauma


How to cite this article:
Tsai PL, Huang CY, Chuang JF, Chou SE, Su WT, Hsu SY, Hsieh CH. Factors affecting mortality in trauma patients with more than three rib fractures. Formos J Surg 2020;53:184-90

How to cite this URL:
Tsai PL, Huang CY, Chuang JF, Chou SE, Su WT, Hsu SY, Hsieh CH. Factors affecting mortality in trauma patients with more than three rib fractures. Formos J Surg [serial online] 2020 [cited 2020 Nov 24];53:184-90. Available from: https://www.e-fjs.org/text.asp?2020/53/5/184/298500




  Introduction Top


Rib fractures are common sequelae after blunt trauma to the chest wall by direct impact or following the exposure to forces of acceleration and deceleration. It is estimated that rib fractures affect approximately 10% of blunt trauma patients admitted to trauma centers.[1] More serious rib injuries are often associated with concomitant fractures of the chest wall, as well as the scapulae, clavicle, and/or sternum.[2] The pain experienced by the majority of patients and deformity of the chest wall resulting from rib fractures may compromise respiratory function[2],[3] and lead to the complications such as pneumonia or acute respiratory distress syndrome.[4] The abdomen, spleen, liver, and kidney (in that order) account for the most commonly injured organs in conjunction with rib fractures.[4] The associated injuries to the head, thorax, and abdomen may be life-threatening.[5],[6],[7] Traumatic brain injury associated with rib fractures is the most common injury responsible for most deaths of patients with rib fractures.[8],[9]

The injury pattern of a rib fracture could be divided into specific groups such as single rib fracture, multiple rib fractures, and flail chest. Patients with multiple rib fractures have significantly worse outcomes than patients with single rib fracture in terms of the rate of chest tube insertion, days on mechanical ventilation, days in the intensive care unit (ICU), length of hospital stay (LOS), rate of complications, and mortality rate.[10] Patients who sustain blunt chest trauma with three or more fractured ribs have a 2-fold increased risk of mortality.[11] The number of rib fractures,[11],[12] age,[11],[12],[13] preexisting comorbidities,[3],[11] pulmonary contusions,[14] and development of pneumonia[11] has been identified as the risk factors for increased mortality of patients. In Taiwan, the trauma mechanisms are different from that in Western countries, as motorcycle and fall accidents comprised most of the trauma injuries.[15],[16],[17] Although the risk factors for mortality have been identified in patients with multiple rib fractures,[18],[19] in Taiwan, such risk factors were less explored in those sustaining higher numbers of rib fractures.[20] This study aimed to explore the risk factors for mortality in patients with more than three rib fractures based on registered trauma data from a Level I trauma center.


  Materials and Methods Top


Ethics statement

This study was approved by the Institutional Review Board (IRB) of Chang Gung Memorial Hospital (approval number 202000055B0). Informed consent was waived according to the IRB regulations.

Data extraction

This retrospective study involved data review from 35,154 trauma patients registered in the Trauma Registry System of a single urban trauma center in Southern Taiwan from January 1, 2009, to December 31, 2018, to identify those who had multiple rib fractures (more than three rib fractures). Of 35,154 enrolled trauma patients, 2,878 (8.2%) patients had sustained a rib fracture [Figure 1]. Patients with less than four rib fractures (n = 1,508) or with incomplete registered data (n = 74) were excluded. Detailed medical information from trauma patients with multiple rib fractures (n = 1,296) was retrieved from the registered database of the Trauma Registry System, including data on age, sex, preexisting comorbidities, including asthma, coronary artery disease (CAD), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), cerebral vascular accident, diabetes mellitus (DM), end-stage renal disease (ESRD), and hypertension (HTN); trauma mechanisms including automobile accidents, motorcycle accidents, bicycle accidents, pedestrian accidents, fall accidents, and strike by/against an object; number of rib fractures; Glasgow Coma Scale (GCS), Abbreviated Injury Scale (AIS) of six body parts (head/neck, face, chest, abdomen, extremities, and external regions); injury severity score (ISS); chest tube insertion at the emergency department (ED); blood transfusion within 24 h; hemoglobin level at the ED; all operations, which included any kind of surgery performed during the admission, and thoracic operations; associated injuries in the thoracoabdominal regions (sternal fracture, diaphragm injury, pulmonary contusion, pneumothorax, hemothorax, hemopneumothorax, hepatic injury, splenic injury, and renal injury); LOS in hospital, admission to the ICU; and in-hospital mortality. The 1998 version of the AIS was used to record the scores.[21] ISS, which represented the severity of injury in patients with multiple injuries, ranged from 1 to 75 and was obtained from the sum of the squares of the three highest AIS scores in different body parts.[22],[23]
Figure 1: Flow chart illustrating the inclusion of patients with more than three rib fractures. Data from the trauma registry system

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Statistical analysis

Statistical analysis was performed using the SPSS version 23.0 window software (IBM Corp., Armonk, NY, USA). Continuous variables were estimated using Levene's test for homogeneity of variance and analyzed using the one-way analysis of variance with Games–Howell post hoc test. The results are expressed as mean ± standard deviation, with GCS and ISS as median and interquartile range (Q1–Q3). Two-sided Fisher's exact or Pearson Chi-square tests were used to compare the categorical data. Odds ratios (ORs) of the associated injuries in the thoracoabdominal regions were calculated with 95% confidence intervals (CIs). Multivariate logistic regression analysis was applied to identify the independent effects of univariate predictive variables resulting in the mortality of patients with multiple rib fractures. P < 0.05 was considered statistically significant.


  Results Top


Patient demographics

As shown in [Table 1], patients were categorized into two groups: mortality (n = 42) and survival (n = 1,254). The average age of patients in the mortality group was higher than that of patients in the survival group (64.2 ± 16.3 vs. 56.0 ± 14.8 years, respectively, P < 0.001). There was no significant difference in gender predominance, preexisting comorbidities, or trauma mechanisms between the two groups. The most common cause of injury was motorcycle accidents (73.8% and 68.8%, respectively), followed by fall accidents (19.0% and 18.2%, respectively). The mortality group had a statistically significantly higher number of rib fractures (6.9 ± 3.0 vs. 5.5 ± 1.7, respectively, P < 0.001), lower GCS score (median [Q1–Q3]; 12.5 [3–15] vs. 15.0 [15–15], respectively, P < 0.001), and higher ISS (median [Q1–Q3]; 35.0 [26–41] vs. 16.0 [13–22], respectively, P < 0.001). The hemoglobin level was statistically significantly lower in the mortality group than the survival group (11.9 ± 2.5 vs. 13.1 ± 2.1, respectively, P = 0.001). A greater percentage of patients in the mortality group had received chest tube insertions (31.0% vs. 12.7%, respectively, P = 0.001) and blood transfusions (61.9% vs. 17.3%, respectively, P < 0.001). The units of transfused blood were significantly higher in the mortality group than the survival group (12.6 ± 13.1 vs. 5.1 ± 5.5, respectively, P < 0.001). There was a significantly greater percentage of patients in the mortality group who had received operations (38.1% vs. 27.3%, respectively, P = 0.032) than the survival group. However, there was no significant difference in the percentage of patients receiving thoracic operation between the mortality and survival group (4.8% vs. 1.7%, respectively, P = 0.136). Patients in the mortality group had a shorter LOS in the hospital (7.7 days vs. 12.9 days, respectively, P = 0.004) and a higher rate of ICU admission (100.0% vs. 36.6%, respectively, P < 0.001) than those in the survival group.
Table 1: Patient and injury characteristics of the mortality and survival groups with multiple rib fractures

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Regarding associated injuries [Table 2], patients in the mortality group had a 10.4-fold higher odds of sustaining sternal fracture (OR, 10.4; 95% CI, 2.04–53.13; P < 0.001), 3.8 fold for pulmonary contusion (OR, 3.8; 95% CI, 1.95–7.58; P < 0.001), and 2.9 fold for hemopneumothorax (OR, 2.9; 95% CI, 1.52–5.45; P < 0.001). There was no significant difference between the mortality and survival groups in terms of diaphragm injury, pneumothorax, hemothorax, hepatic injury, splenic injury, or rental injury. The mortality group had statistically significantly higher odds of sustaining an injury to the head/neck (OR, 6.7; 95% CI, 3.40–13.28; P < 0.001) and face (OR, 3.1; 95% CI, 1.47–6.40; P = 0.002), as well as a higher AIS score in the head/neck, face, thorax, and extremity.
Table 2: Associated injuries observed in the thoracoabdominal region and the abbreviated injury scale for each body part

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Risk factors for mortality

Univariate logistic regression analysis [Table 3] demonstrated that the significant risk factors for mortality in patients with multiple rib fractures were age, number of rib fractures, GCS, ISS, chest tube insertion, blood transfusion, associated sternal fracture, pulmonary contusion, hemopneumothorax, and AIS of head. Multivariate logistic regression analysis revealed that age (OR, 1.1; 95% CI, 1.05–1.12; P < 0.001), number of rib fractures (OR, 1.2; 95% CI, 1.04–1.47; P = 0.015), GCS (OR, 0.8; 95% CI, 0.76–0.93; P = 0.001), ISS (OR, 1.2; 95% CI, 1.10–1.21; P < 0.001), blood transfusion (OR, 4.3; 95% CI, 1.37–13.40; P = 0.013), and hemopneumothorax (OR, 15.5; 95% CI, 2.76–86.62; P = 0.002) were the significant independent risk factors for mortality in trauma patients with multiple rib fractures. Chest tube insertion, sternal fracture, pulmonary contusion, and AIS of head were not identified as the independent risk factors in mortality in these patients.
Table 3: Univariate and multivariate analysis to identify the risk factors for mortality in patients with multiple rib fractures

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  Discussion Top


This study revealed that age, number of rib fractures, GCS, injury severity, the blood transfusion, and hemopneumothorax were the significant independent risk factors for mortality among patients with more than three rib fractures. Furthermore, the AIS of the head did not represent as one independent risk factor for mortality.

A systematic review of 29 studies involving patients with blunt chest trauma showed that age (65 years or more) and the number of rib fractures are the most important risk factors for mortality.[11] This is not surprising because a higher amount of energy is required to fracture more ribs, and the ribs of the elderly are weaker and thus prone to fracture.[12],[13],[24] A linear relationship exists between the number of rib fractures and the mortality rate among elderly patients; the greater the number of rib fractures, the higher the mortality rate.[13] A higher number of rib fractures is also associated with an increased rate of pulmonary complications.[25] In young adults, death resulting from blunt chest trauma is generally attributed to trauma-associated injuries, while in the elderly, mortality is often directly related to pneumonia and progressive respiratory failure.[13],[24],[26]

This study revealed that patients with multiple rib fractures who died had a higher ISS than those who survived. The higher ISS and mortality outcome were attributed to head injuries associated with thoracic trauma. The mortality group had sustained significantly higher AIS injury to the head/neck and presented with a significantly lower GCS score than the survival group. It had also been demonstrated that mortality in patients with rib fractures is affected by the presence of traumatic brain injury.[27] Clark et al.[8] and Stellin[9] found that traumatic brain injury is the most common associated injury in patients with rib fractures after separately examining 144 and 203 patients. In addition, most deaths in patients with rib fractures are caused by traumatic brain injury and shock rather than by pulmonary failure.[8],[9] Traumatic brain injury was responsible for a significant number of deaths in younger patients, independent of the number of rib fractures.[19] In contrast, the most common cause of death in the very elderly was pulmonary failure.[19]

In addition to tension pneumothorax, the massive hemothorax is another immediate life-threatening condition.[28] Hemorrhagic shock is the leading cause of death in patients with thoracic trauma.[29] Among 57 patients presenting with flail chest injury, blood transfusion was identified as one of the primary factors associated with an adverse outcome.[30] In this study, there was a significantly lower level of hemoglobin and greater percentage of patients receiving blood transfusions in the mortality group than the survival group. It is not surprising that blood transfusion is associated with a higher risk of mortality in patients with multiple rib fractures. However, because this was a retrospective study, the indication for blood transfusion was unknown; therefore, the value of such information may be limited and requires further investigation.

Univariate analysis demonstrated a statistically significant difference in age, number of rib fractures, GCS, ISS, chest tube insertion, blood transfusion, associated sternal fracture, pulmonary contusion, hemopneumothorax, and AIS of head between the mortality and survival groups. In contrast, statistically significant differences were limited to age, number of rib fractures, GCS, ISS, blood transfusion, and hemopneumothorax in the multivariate analysis. In this study, the GCS, but not the AIS of head, represented as one independent risk factor for mortality. The reason may be explained by that the GCS indicates a substantial change of consciousness after traumatic brain injury while AIS of head reflects an injury to the head but with a quite wide range. In this study, there were 18.3% (237/1296) of patients with multiple rib fractures had hemopneumothorax, and such incidence is comparable to report 20% in the literature.[31] In the assessment of 539 consecutive patients with multiple rib fractures, hemopneumothorax was positively associated with indicators of injury severity.[32] The occurrence of hemopneumothorax implies severe injury to the thoracic cage and presents as one independent risk for mortality. To drain the air or blood accumulated inside the chest wall, the chest tube insertion is traditionally advocated to allow better ventilation. In this study, although univariate analysis showed a statistically significant difference in chest tube insertion between the mortality and survival groups, its beneficial effect was not identified in the multivariate analysis. The advantageous effect provided by chest tube insertion in these severely injured patients may be limited to make a difference regarding the patient's survival. However, this hypothesis requires further investigation in the prospective and controlled study.

Flail chest is three or more ribs broken in two or more places and indicates a segment that is disconnected from the rest of the chest wall and moves paradoxically inward with inspiration. In a study of 117,204 patients with chest wall fractures, 1.5% of patients had a flail chest, 41% had multiple rib fractures, and 58% had single rib fractures.[10] The incidence of flail chest in patients with rib fracture is low; however, the flail chest carries a higher risk of mortality ranging from 16%[33] to 25%,[34] in comparison with the 3.2% (42/1296) mortality rate of patients with multiple rib fractures in this study. The registered trauma database did not record the status of the flail chest of the patients in the system; therefore, a bias may be encountered on the outcome measurement.

Limitations

There were some other limitations in this study. Selection bias may be present in the retrospective design of this study. Unknown conditions such as resuscitation, damage control, and surgical intervention could lead to a bias. We assume that patient management by different trauma surgeons was uneventful. It has been reported that plate fixation of fractured ribs provides a significant benefit,[35],[36],[37],[38],[39] but the effect on survival is unknown. In this study population, few patients had received plate fixation; however, the effects of this procedure are unknown and may lead to bias in the outcome. Furthermore, the registered trauma database used in this study excluded patients that were declared dead at the scene of the accident and only recorded cases of in-hospital mortality. For example, those patients who died of tension pneumothorax with the failed intervention were unknown and not recorded, thus may lead to bias in the outcome assessment. The data obtained for this study did not include long-term mortality; therefore, results may not fully reflect the scope of mortality associated with multiple rib fractures. Because the population included in this study was limited to that from a single urban trauma center in Southern Taiwan, these results may not apply to other regions.


  Conclusion Top


This study revealed that age, number of rib fractures, GCS, ISS, blood transfusion, and hemopneumothorax were the significant independent risk factors for mortality in patients with more than three rib fractures.

Acknowledgments

We would like to thank the Biostatistics Center of Kaohsiung Chang Gung Memorial Hospital for their statistics work.

Financial support and sponsorship

This research was financially supported by a grant from CDRPG8J0031.

Conflicts of interest

There are no conflicts of interest.



 
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